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As Congress considers repealing the Affordable Care Act, health professionals in Kentucky, Ohio, and West Virginia grapple with what that might mean for a region where many depend on the law for access to care. This occasional series from the ReSource explores what’s ahead for the Ohio Valley after Obamacare. See more stories here >>

It’s hard to find a spot on the map where the proposed repeal of the Affordable Care Act would have a bigger effect than in the Ohio Valley. By one measure, for example, the proposal could mean West Virginia’s rate of people who lack health insurance would climb by nearly 300 percent — the biggest such change in the country. The projected declines in Kentucky and Ohio are also more than twice the national average. This is largely due to proposed changes in Medicaid.

Urban Institute

As Congress debated Republican health measures that would roll back the ACA’s expansion of Medicaid, the full extent of Medicaid’s role in Kentucky, Ohio, and West Virginia gained more public attention. Rural hospitals, people living with disabilities, displaced coal miners, addiction treatment services, care for the elderly — all could be affected by cuts to Medicaid.

That rising awareness has focused public attention, sparked protest, and put some regional lawmakers on the spot.

As the ramifications of proposed changes to the ACA became clear, more health care providers began to speak up about the widespread but less obvious ways that Medicaid supports their work.

Hospital officials say Medicaid has been crucial in keeping rural hospitals open. The Kentucky Hospital Association estimates that rural hospitals and health centers in the state receive about 70 percent of their revenue from Medicare and Medicaid.

Teresa Fleming is the financial officer for one of those rural health centers, Mountain Comprehensive Care, which serves five eastern Kentucky counties. Fleming said the expansion of Medicaid came just as many coal miners in the region were losing jobs and health coverage.

“The Affordable Care Act came at the right time and basically correlated with the mine layoffs,” she said. “So that gave our patients safety or at least some security that they would have some kind of coverage so they could go see their providers.”

Services supported by Medicaid also allow people with disabilities to live in their communities and outside of institutions. According to the Kaiser Family Foundation nearly 760,000 people with disabilities in Kentucky, Ohio, and West Virginia depend on Medicaid.

Jeff Edwards, executive director of Kentucky Prevention and Advocacy, said those services allow people with disabilities to lead fuller lives and contribute to their communities.

“When we hear they are going to dismantle Medicaid we are thinking about adults, people who need some help in the morning to get dressed and get in a wheelchair but then go on to work a 40-hour-a-week job,” he said.

If those services are cut, he said, “We will start filling institutions back up.”

The Addiction Factor

The ACA allowed more people suffering with addiction to get more resources, according to treatment specialists throughout the region.

Looking just at numbers from the Medicaid expansion through the ACA, researchers at Harvard and New York University estimate nearly 215,000 additional people were able to seek addiction and mental health treatment.

In Portsmouth, Ohio, a city hit hard by the addiction crisis, the health department was able to connect more people to treatment thanks to the coverage gains.

Portsmouth, Ohio, public health nurse Lisa Roberts saw what happens when addiction treatment abruptly ends. “It could just be catastrophic.”

The progress they’ve made could be lost under the proposed repeal plans because Scioto County, where Portsmouth is located, also struggles with unemployment.

“So many of our people depend on types of insurances that would go away,” Lisa Roberts, a public health nurse with the department said. “We just have a lot of people here who don’t have access to good, regular, employee-covered health insurance.”

This resonates with Ohio Valley politicians considered to be key votes in the repeal effort.

Republican Senators Rob Portman of Ohio and Shelley Moore Capito of West Virginia both cited the potential loss of coverage and funding for addiction treatment as reasons they would oppose the current Senate plan.

Senate leaders attempted to win back their support with the promise of $45 billion in addiction treatment funding spread out over about a decade, up from $2 billion in an earlier version of the bill.

But treatment specialists and state leaders say that’s far from enough to make a difference.

Ohio’s Republican Gov. John Kasich said on ABC’s “This Week” that the funding was “like spitting in the ocean. It’s just not enough.”

The left-leaning Center for American Progress estimates that Kentucky, Ohio, and West Virginia would get a $443 million share of the funds per year over that time period. But the CAP analysis estimated the full cost of treatment in Ohio alone would be over $2 billion by 2026.

It’s difficult to predict these numbers with complete accuracy due to the changing nature of the opioid epidemic and state investments in more treatment efforts. But numbers like these are enough to give Senators Portman and Capito pause when considering a repeal effort.

Public Protests

Sen. Capito and other regional lawmakers have also been the focus of newly energized activists who have organized numerous sit-ins, marches, and other events that saw people taking to the streets, even in some places that are deep-red in their politics.

The demonstrations frequently included people with disabilities or health problems advocating for themselves — people in wheelchairs or those with chronic conditions who couldn’t stand for long but who turned out anyway. Many independent, grassroots groups coordinated via social media to create “pop up” protests at every turn of the legislative process.

Demonstrators were also fueled by fresh reminders from emerging science showing just how important health care access is in the area.

A study published in the Journal of the American Medical Association’s publication, JAMA Internal Medicine, made headlines during the health debate for its conclusions that in parts of the Ohio Valley people can now expect to live shorter lives than their parents did.

The study found that Kentucky, Ohio, and West Virginia include 27 of the 50 counties with the country’s worst trends in life spans. Of the 10 counties in the U.S. with the worst declines in life expectancy, eight are in Kentucky.

It’s difficult to say what effect the activism has had on decision makers, but the correlations provide some indication. After activists staged sit-ins in her offices, for example, Sen. Capito issued a statement voicing her concerns with the Senate’s repeal-and-replace bill.

“I did not come to Washington to hurt people,” she wrote.

Conflicting Claims

The protesters and Republican supporters of the bill had starkly conflicting messages about Medicaid’s future. Protesters often cited the Congressional Budget Office estimate that 22 million people could become uninsured under the Republican plan, due in part to Medicaid changes.

Kentucky Republican Sen. Mitch McConnell, the Senate’s Majority Leader, had a very different message when responding to a protest at a recent event in Paducah, Kentucky.

“Nothing that we’ve advocated so far would cause anybody currently on Medicaid to be taken off of Medicaid,” he said.

Simon Haeder is an assistant professor at the John D. Rockefeller IV School of Policy and Politics at West Virginia University, where he focuses on health care policy. Haeder said McConnell parsed his words carefully to make that argument, emphasizing people who “choose” to leave. That would include people who signed up for health insurance only because the original ACA mandated that coverage.

But Haeder points out that many who qualified for Medicaid under the ACA’s expansion would likely make that “choice” to leave Medicaid only because they would find they could not re-enroll after revisions to guidelines for Medicaid qualification.

Many families are eligible for Medicaid under expanded ACA income guidelines that gave that option to more working class people. If those expanded income guidelines are rolled back, Haeder explained, people wouldn’t technically get “kicked off” of Medicaid but they would no longer be eligible to continue their Medicaid enrollment because their income was too high.

“The semantics are there to work with, I guess,” Haeder said of McConnell’s claim, “but the reality is very, very different.”

Others, he said, could be pushed off Medicaid and not be able to afford private insurance premiums. It’s also hard to predict an ever-shifting population of those who are eligible for Medicaid.

Not Over

Haeder said the ongoing debate helped educate people about the scope of Medicaid. A wide variety of groups from the American Medical Association and AARP to grassroots activists voiced their concerns.

Haeder said that despite the apparent demise of the latest Senate bill, that conversation will continue, as will the legislative efforts to change the health care system.

“A lot of the stuff that is being discussed like the cuts to Medicaid can come back really, really quickly,” he said. “For example, in the budget negotiations coming up. It is not over by any stretch of the imagination.”